两种方法冠状动脉旁路移植术后心电图及心肌损伤标志物变化的对比和意义

目的探讨体外循环冠状动脉旁路移植术（CABG）与非体外循环冠状动脉旁路移植术（OPCABG）后ECG及心肌损伤标志物变化的临床意义。方法监测25例冠心病患者OPCABG术后（OPCABG组）不同时间点ECG V4、V5导联的R波振幅的变化，同时测定不同时间点的肌酸磷酸激酶同功酶MB（CPK—MB）、肌钙蛋白I（cTnI）和热休克蛋白70（HSP70）水平，并与同时期25例行体外循环CABG的冠心病患者（CABG组）进行比较。结果OPCABG组术后0．6、18、24h ECG V4、V5导联R波振幅与术前比较差异无统计学意义，而CABG组术后0、6、18h ECG V4、V5导联R波振幅较术前明显下降（P〈0．01），24hR波振幅逐渐恢复至术前水平；CABG组CPK—MB和cTnI水平在术后24h达到峰值，且中位峰值水平明显高于OPCABG组（29．29 μg／L比5．98 μg／L，6．74 μg/L比1．91 μg／L）。两组的HSP70水平在术后6h皆达到峰值，但CABG组中位峰值水平显著高于OPCABG组（11044．5 pmol／L比1702．0 pmol／L）。在术后第1天HSP70水平与CPK—MB（r=0．370，P〈0．01）、cTnI（r=0．458，P〈0．01）存在相关性。结论OPCABG与体外循环CABG比较，对心肌损伤明显减小，HSP70水平能提示心肌细胞的损伤程度。     

两种方法冠状动脉旁路移植术后心电图及心肌损伤标志物变化的对比和意义

目的 探讨体外循环冠状动脉旁路移植术(CABC)与非体外循环冠状动脉旁路移植术(OPCABG)后ECG及心肌损伤标志物变化的临床意义.方法 监测25例冠心病患者OPCABG术后(OPCABG组)不同时间点ECG V4、V5导联的R波振幅的变化.同时测定不同时间点的肌酸磷酸激酶同功酶MB(CPK-MB)、肌钙蛋白I(cTnI)和热休克蛋白70(HSP70)水平,并与同时期25例行体外循环CABG的冠心病患者(CABG组)进行比较.结果OPCABG组术后0、6、18、24 h ECG V4、V5导联R波振幅与术前比较差异无统计学意义.而CABG组术后0、6、18 hECG V4、V5导联R波振幅较术前明显下降(P<0.01),24h R波振幅逐渐恢复至术前水平;CABG组CPK-MB和cTnI水平在术后24 h达到峰值,且中位峰值水平明显高于OPCABG组(29.29 μg/L比5.98μg/L,6.74μg/L比1.91μg/L).两组的HSP70水平在术后6 h皆达到峰值,但CABG组中位峰值水平显著高于OPCABG组(11044.5 pmol/L比1702.0 pmol/L).在术后第1天HSP70水平与CPK-MB(r=0.370,P<0.01)、cTnI(r=0.458,P<0.01)存在相关性.结论 OPCABG与体外循环CABG比较,对心肌损伤明显减小,HSP70水平能提示心肌细胞的损伤程度.     

Relation between preoperative mild increased in serum creatinine level and early outcomes after coronary artery bypass grafting

This study evaluates the effect of preoperative increased level of serum creatinine (Cr) on early outcomes after coronary artery bypass graft surgery (CABG). 1140 patients who underwent CABG in our center were studied. Patients with Cr >2.25 mg/dl or preoperative dialysis and who had off-pump operations were excluded. Group 1 consisted of 892 patients with normal Cr (0.5-1.2 mg/dl) and group 2 consisted of 248 (21.8%) patients with mild increased level of serum Cr (1.3-2.2 mg/dl). Patients in group 1 were younger than group 2. There were more patients with hypertension in group 2, but there were not statistically significant difference between two groups in terms of the frequency of diabetes, smoking, cerebrovascular disease and New York Heart Association (NYHA) class. Left ventricular ejection fraction (LVEF) was lower in group 2. Cardiopulmonary bypass time (CPB) was longer in group 2. Early mortality was 3.2% in group 1 and 8.4% in group 2 (P<0.001). Prolonged ICU stay, low cardiac output, prolonged mechanical ventilation, postoperative atrial fibrillation, postoperative re-exploration and sepsis were more frequent in group 2. Mild increase in serum Cr level preoperatively is a marker of increased early mortality and outcome after CABG.     

微创不停跳冠状动脉旁路移植术128例分析

目的回顾性分析微创不停跳冠状动脉旁路移植术(OPCABG)的方法、围术期处理和临床效果。方法自2000年7月～2009年7月,128例冠心病患者接受OPCABG,占同期冠心病手术的32%。平均年龄61.7岁,左室射血分数24%～70%。平均搭桥2.4根。结果本组手术死亡4例,死亡率3.1%。术后8例出现严重并发症,发生率为6.3%。ICU时间平均2.1天。术后平均随访38个月,心绞痛消失率90.0%。结论 OPCABG是安全、可行的,尤其适用于体外循环高危患者,临床效果满意。     

Beating heart coronary revascularisation. Report of 26 cases

The beating heart coronary artery bypass technique is becoming more popular in many cardiac units throughout the world. This relativity new technique has prompted surgeons and anaesthetists to review and analysed the routine approach to coronary surgery. In this study we reviewed 26 patients operated off pump technique group I (50 %) and the group II (50 %) operated on pump coronary artery bypass. The patients in the group II were more symptomatic with more heart function, than group I. The postoperative cause of the two groups was similar. This retrospective analysis shows that beating heart technique for coronary surgery can be offered to many patients with good out come and on pump technique can be more safety specially in case of poor myocardial function.     

冠状动脉旁路移植术治疗冠心病的临床应用研究

目的报告冠状动脉旁路移植手术（CABG）治疗冠心病的早期结果及分析。方法对270例冠心病患者行冠状动脉旁路移植手术,应用体外循环（ONCABG）63例,非体外循环（OPCABG）207例;不稳定型心绞痛130例,陈旧性心肌梗死96例,室壁瘤15例;多支病变188例,二支病变61,左主干病变21例：合并糖尿病86例,高血压91例,瓣膜病32例,均于术中同期手术处理。结果手术平均每例搭桥3.16支,术后需用IABP支持治疗8例,无围手术期心肌梗死。早期死亡1例;患者术后心绞痛症状消失,生活质量明显提高。结论 CABG手术治疗冠心病临床效果好,充分的术前准备,熟练的手术技术是手术成功的关键：对高龄、多支病变、陈旧心梗并发症及心功能较差的患者仍具有良好的安全性。     

Analysis of the stable metabolite of endothelium-derived nitric oxide of internal mammary artery bypass grafts at the venous drainage system of the recipient coronary artery. Morphologic implications and consequences

INTRODUCTION: The internal mammary artery's endothelium continuously produces nitric oxide in a large quantity resulting in local and downstream vasodilatation, inhibition of platelet aggregation and in the tunica media prevents smooth muscle cell proliferation. OBJECTIVE: The aim of this study was to measure the concentration of the internal mammary artery bypass graft's endothelium derived nitric oxide's stable metabolite, (nitrite) at the venous drainage site (great cardiac vein) of the recipient coronary artery (left anterior descending), and to prove that the change of the biochemical milieu provides morphological stability (vasodilation and lack of atherosclerosis) in the recipient coronary artery based on recoronarographies. METHOD: Authors investigated the levels of endothelium derived nitric oxide in intraoperative settings of 50 off pump, partly heparinized coronary bypass surgery cases sampling from the internal mammary free cut end flow (81.2 +/- 12.1 mumol/l), the great cardiac vein (anterior interventricular vein) prior and after arterial bypass graft completion and in the systemic circulation (42.9 +/- 7.1 mumol/l), The stable metabolite concentration measurement was carried out with the modified Takafumi Ohta method utilizing fluoroscopy. Out of the 200 samples 164 were feasible to analyze. RESULTS: A significant increase was found in the great cardiac vein, comparing concentrations measured prior and after IMA anastomosis completion: 46.7 +/- 11.4 mumol/l, and 71.12 +/- 13.1 mumol/l, respectively (p < 0.05). CONCLUSION: Based on these findings, due to the continuous protective (vasodilatative and antiatherogen) effect of the IMA provided EDNO, the recipient artery shows no pathological changes in time. This was proved by studying recoronarographies of 103 patients--with prior coronary bypass surgery in 5-12 years using the IMA, and with new symptomatology. Out of 87 functioning IMA to LAD grafts, 85 LAD showed no atherosclerotic changes, while in the same patients' other coronary systems significant, de novo stenotic lesions had developed.     

非体外循环和体外循环冠状动脉旁路移植术的临床对比研究

目的 比较非体外循环冠状动脉旁路移植术(off-pump CABG)和体外循环冠状动脉旁路移植术(on-pump CABG)的临床效果.方法 回顾性分析2005年6月至2008年12月行冠状动脉旁路移植术152例患者的临床资料,其中off-pump CABG 85例(观察组),On-pump CABG 67例(对照组),对两组术后病死率、并发症发生率进行比较.结果 观察组术后死亡2例(2.35%),出现并发症13例(15.29%);对照组术后死亡9例(13.43%),出现并发症25例(37.31%).观察组术后病死率和并发症发生率均比对照组低,差异有统计学意义(P<0.01 .结论 off-pump CABG是安全的、微创的手术治疗方法.     

Coronary surgery at the Cardiovascular Surgical Clinic (1976-1990)]

In the Cardiovascular Surgical Clinic of the Semmelweis Medical University of Budapest the first coronary artery bypass grafting (CABG) procedure was performed in 1975. Since that time coronary artery surgery has become a routine everyday practice representing more than half of the total workload of adult cardiac surgery. The analysis of 1347 operations performed between 1976-1990 on patients with coronary heart disease showed the followings: the first few years--so called learning curve of CABG operations is characterised by high mortality. With passing time the number of cases performed each year increased rapidly and the surgical technique has improved too. At the same time the operative mortality figures showed decreasing tendency--it was 2.1% for the last 609 cases. All observed parameters showed some progress: in 1990 the average number of grafts per patient was 3.09, internal mammary artery usage 15 percent and the mean aortic cross clamp time per anastomosis 24.5 minutes. Complete myocardial revascularisation is the key point of coronary artery surgery. In order to achieve this target in all operated cases further technical improvement is necessary.     

舒芬太尼麻醉用于心血管手术的多种临床研究

目的：探讨舒芬太尼用于多类型心血管手术的临床效果。方法：选取包括本院在内10所医院的400例在低温、全身麻醉和心肺转流条件下施行冠状动脉搭桥术和／或心脏瓣膜置换术的患者,随机分为两组,舒芬太尼组300例,芬太尼组100例,舒芬太尼组给予舒芬太尼和咪唑安定进行手术麻醉,芬太尼组给予芬太尼和肌松药,记录两组麻醉诱导前后和手术后的各项指标及不良反应以分析临床效果。结果：两组麻醉过程顺利,无明显不良反应,在手术后恢复良好。舒芬太尼组和芬太尼组的所有病例麻醉诱导后的心率、平均动脉压均较诱导前明显降低（P〈0．05）,中心静脉压在诱导后较诱导前高（P〈0．05）,瓣膜组气管插管后,舒芬太尼组的中心静脉压明显高于芬太尼组（P〈0．05或P〈0．01）,搭桥组在麻醉诱导后和气管插管后1、5、10min,舒芬太尼组的心率和平均动脉压均明显低于芬太尼组（P〈0．05或P〈0．01）,气管插管后,舒芬太尼组的中心静脉压明显高于芬太尼组（P〈0．05或P〈0．01）。舒芬太尼组诱导总量和诱导浓度均明显低于芬太尼组。组间术后清醒时间和拔管时间比较差异无统计学意义（P〉0．05）。结论：舒芬太尼和芬太尼分别麻醉用于心血管手术均有良好、安全的效果,但舒芬太尼对血流动力学因素的影响更小,是较为理想的麻醉方法。     

先天性心脏病伴重度肺动脉高压体外循环术后拔管时机探讨

目的 探讨先天性心脏病(CHD)伴重度肺动脉高压(PH)体外循环(CPB)术后的拔管时机.方法 对行CPB手术的40例CHD伴重度PH患者的临床资料进行回顾性分析,按术后机械通气时间是否>24h,分为早期拔管组(19例)和延迟拔管组(21例),比较两组影响拔管的围手术期因素.行多因素Logistic回归分析确定延迟拔管(机械通气时间≥72 h)的影响因素.结果 两组术前NYHA心功能分级、撤机后肺循环与体循环收缩压比值(Pp/Ps)、CPB时间、CPB温度比较差异有统计学意义(P<0.05或<0.01).术后早期缺氧发作(OR=0.022,95%CI0.001～0.580)和严重低氧血症(OR=0.031,95%CI0.002～0.568)是延迟拔管的独立危险因素.结论 CHD伴重度PH患者若术前NYHA心功能分级≥Ⅲ级、撤机后Pp/Ps>0.5、CPB时间>90 min或CPB温度<32℃,可考虑延迟拔管.对术后早期有缺氧发作或严重低氧血症者,宜延迟拔管并加强心功能和肺动脉压监测;对无上述情况且术后心肺功能稳定者可考虑早期拔管.     

先天性心脏病伴重度肺动脉高压体外循环术后拔管时机探讨

目的探讨先天性心脏病（CHD）伴重度肺动脉高压（PH）体外循环（CPB）术后的拔管时机。方法对行CPB手术的40例CHD伴重度PH患者的临床资料进行回顾性分析,按术后机械通气时间是否〉24h,分为早期拔管组（19例）和延迟拔管组（21例）,比较两组影响拔管的围手术期因素。行多因素Logistic回归分析确定延迟拔管（机械通气时间≥72h）的影响因素。结果两组术前NYHA心功能分级、撤机后肺循环与体循环收缩压比值（Pp／Ps）、CPB时间、CPB温度比较差异有统计学意义（P〈0．05或〈0．01）。术后早期缺氧发作（OR=0．022,95％CI0．001～0．580）和严重低氧血症（OR=0．031,95％CI0．002～0．568）是延迟拔管的独立危险因素。结论CHD伴重度PH患者若术前NYHA心功能分级≥Ⅲ级、撤机后Pp／Ps〉0．5、CPB时间〉90min或CPB温度〈32℃,可考虑延迟拔管。对术后早期有缺氧发作或严重低氧血症者,宜延迟拔管并加强心功能和肺动脉压监测;对无上述情况且术后心肺功能稳定者可考虑早期拔管。     

冠状动脉旁路移植术预防用药干预效果分析

目的讨论冠状动脉旁路移植术(CABG)预防用药干预效果。方法应用统计学方法,对预防用药干预后3个月和干预前1年同期CABG手术病例进行对比分析。结果干预组较对照组平均住院日缩短1.38 d,死亡率下降1.34%;干预组手术采用头孢呋辛预防用药占72.15%,单联预防用药病例医院感染发病率低于对照组,差异有统计学意义(P<0.05);干预组手术切口感染率降低了0.44%,平均住院日缩短17.34 d;通过干预,手术当日预防用药级别降低,联合用药减少,杜绝了≥3种预防用药,手术当日预防用药类别趋于合理。结论医院对心脏手术选择二代头孢菌素的干预措施是有效的;应当把监测数据反馈临床,使外科医师建立信心,提高合理用药的依从性,进一步巩固干预成果;对于心脏外科手术预防用药的干预仍需不断探索,深入进行。     

强化胰岛素治疗对老年非糖尿病患者体外循环冠脉搭桥术的影响

目的探讨强化胰岛素治疗对老年非糖尿病患者体外循环（CPB）冠状动脉旁路移植术（CABG）后炎症反应的及其预后的影响。方法对2005年6月至2010年6月在本科行体外循环下冠状动脉旁路移植术的非糖尿病老年患者（〉60岁）进行回顾性分析。将前期共24例未行胰岛素强化治疗的患者作为对照组：自术后将血糖控制在10．0～11．1mmol／L;将后期36例行胰岛素强化治疗的患者作为治疗组：从麻醉开始起即用胰岛素泵严格控制血糖,将血糖控制在4．4-6．1mmo／／L。对两组患者术后感染、呼吸机辅助通气时间、住院时间及死亡率等指标进行对比研究。结果60例非糖尿病老年冠心病患者被纳入研究,两组患者的性别、体质量、诊断及合并疾病、手术方法及体外循环时问等手术资料差异无统计学意义（P〉0．05）。强化胰岛素治疗组术后白细胞计数[（12．6±2．8）×10^9／LVS（18．8±3．1）×10^9／L],呼吸道感染（6／36VS10／24）及切口感染率（2／36VS6／24）、术后恶性心律失常发生率（2／36VS6／24）等指标降低,术后住院时间缩短[（12．2±3．7）dVS（15．6±5．4）d）],与常规治疗组比较差异均有统计学意义（P〈0．05）。结论围手术期强化胰岛素治疗可降低老年非糖尿病体外循环冠脉搭桥患者术后并发症发生率,缩短住院时间,改善临床预后。     

70岁以上冠状动脉旁路移植手术患者术中以乳内动脉建立左前降支旁路的应用评价

目的 探讨70岁以上冠状动脉旁路移植手术患者术中应用乳内动脉建立左前降支旁路的利弊.方法 2009年1月至2014年1月共收治288例70岁以上患者行单纯冠状动脉旁路移植手术.按移植血管材料分为两组：对照组138例患者全部使用大隐静脉;观察组150例患者应用左乳内动脉建立左前降支旁路,其中7例应用桡动脉及胃网膜右动脉进行全动脉化旁路移植手术,其余靶血管均应用大隐静脉作为血管移植物旁路移植.结果 对照组死亡4例（2.9％,4/138）,观察组死亡3例（2.0％,3/150）,两组病死率比较差异无统计学意义（p＞0.05）.观察组术后24 h引流量（796.2±382.4） ml,明显高于对照组的（512.8±387.5） ml,差异有统计学意义（P＜0.05）;而二次开胸止血、恶性心律失常、卒中、切口愈合不良和主动脉内球囊反搏使用例数等指标两组比较差异均无统计学意义（P＞ 0.05）.结论 70岁以上高龄患者旁路移植冠状动脉选择左乳内动脉作为左前降支的旁路移植血管材料,不增加手术死亡和术后严重并发症的发生率.     

Clinical outcome and cost in patients with off-pump vs. on-pump coronary artery bypass surgery

General concept and major emphasis on off-pump coronary artery bypass surgery (OPCAB) is maintaining quality of care and patient safety while reducing cost and resource utilization. OPCAB probably avoids the potential complications of cardiopulmonary bypass. However its acceptance depends on clinical and economic outcome. The aim of this study is to compare clinical and economic outcome of off-pump and on pump coronary artery bypass surgery. This is a report of an analytic cross-sectional study on 304 patients underwent coronary artery bypass surgery that were randomized into conventional on pump and off-pump groups. Variables and costs were obtained for each group and these data were analyzed using parametric methods. There was no difference between the two groups with respect to perioperative and intraoperative patient's variables. OPCAB reduced the need for postoperative transfusion requirement (P<0.05) which was statistically significant and showed a trend towards reduction of morbidity although didn't reach statistical significance (P>0.05). There were no statistically significant differences in surgical re exploration and length of stay between the two groups. The mean cost for an on pump surgery was 8312000 ± 2859 Rials per patient that was significantly higher than an off-pump surgery. Based on the findings of this study, clinical outcome has no statistically significant difference between on pump and off-pump CABG but the costs are significantly higher in the on pump group.     

Fewer lung complications following inspiratory muscle training in patients undergoing coronary bypass surgery: a randomized trial

OBJECTIVE: The aim of this study was to evaluate the prophylactic efficacy of preoperative physiotherapy, including inspiratory muscle training (IMT), on the incidence of postoperative pulmonary complications (PPCs) in high-risk patients scheduled for elective coronary artery bypass grafting (CABG). DESIGN: Randomized controlled clinical trial (www.controlled-trials. com/isrctn17691887). METHOD: Of 655 patients referred to a university medical centre in The Netherlands for elective CABG, 299 met the criteria for being at high risk of developing PPCs. A total of 279 were enrolled and monitored up to discharge from hospital. Patients were randomly assigned to receive either preoperative IMT (n=140) or usual care (n=139). Both groups received the same postoperative treatment. RESULTS: Both groups were comparable at baseline. Before CABG, 2 control group patients and 1 IMT group patient died. After CABG surgery, PPCs were present in 25 (18%) of 139 patients in the IMT group and 48 (35%) of 137 patients in the control group (OR: 0.52; 95% CI: 0.30-0.92). Pneumonia occurred in 9 (6.5%) of 139 patients in the IMT group and in 22 (16.1%) of 137 patients in the usual care group (OR: 0.40; 95% CI: 0.19-0.84). Mean duration of postoperative hospitalization was 7 (range 5-41) days in the IMT group versus 8 (range 6-70) days in the usual care group (Mann-Whitney test; Z: -2.42; p = 0.015). CONCLUSION: Preoperative physiotherapy, including IMT, statistically significantly reduced the incidence ofPPCs and the duration ofpostoperative hospitalization in patients at high risk of developing a pulmonary complication on undergoing CABG.     

Hemodynamic effects of propofol induction administered with target controlled infusion pump in patients scheduled for open heart surgery

Target controlled infusion systems have been developed to provide improved convenience and control during intravenous anaesthesia. The anaesthetist sets and adjust the target blood concentration and depth of anaesthesia--as required on clinical grounds. Infusion rates are altered automatically according to a validated pharmacokinetic model. Haemodynamic effects during induction of anaesthesia with target controlled infusion pump have been documented in this prospective study. Twenty patients scheduled for open heart surgery. Mean age 62.2 +/- 9.93 years. The surgical procedures were: 16 coronary bypass, 2 artificial valve replacement, 2 coronary bypass combined valve replacement. Anaesthesia was induced with alfentanil, 20-40 micrograms/kg, and propofol administered with target control infusion pump, 1.5-4 micrograms/ml target concentration. Pulse contour analysis was used for haemodynamic measurements. They were repeated before induction (T0), after induction--before intubation (T1), after intubation in two minutes intervals (T2-T5). Compared with values obtained in awake patients, there was a significant decrease in mean arterial pressure (-30%), in cardiac output (-25%), in heart rate (-8%), in vascular resistance (-9%), in contractility (-37.4%), in stroke volume (-17.5%). No ECG changes were observed during that period. The haemodynamic changes observed do not differ from the published data in patients presenting for cardiac surgery and anaesthetized with manually controlled infusion techniques using propofol.     

冠状动脉三支病变患者不同血运重建策略的预后比较

[目的]比较冠状动脉三支病变患者经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)和冠状动脉旁路移植术(coronary artery bypass grafting,CABG)的预后。[方法]回顾性分析了首次行血运重建治疗的冠状动脉三支病变患者233例,其中PCI组160例,CABG组73例,比较两组患者2年的不良心脑血管事件(包括全因死亡;全因死亡和非致死性卒中/心肌梗死联合终点;再次血运重建术)。[结果]CABG组的2年再次血运重建率低于PCI组,但由于术后院内死亡率较高导致CABG组2年全因死亡发生率高于PCI组(P﹤0.05),2年主要不良心脑血管事件发生率(major adverse cardiac and cerebrovascular events,MACCE)、2年全因死亡和非致死性卒中/心肌梗死联合终点发生率两组间差异无统计学意义(P﹥0.05)。[结论]冠状动脉三支病变患者2年联合终点事件发生率两组间并无差异,但PCI组的2年再次血运重建率仍高于CABG组。     

Volume and quality of care in coronary artery bypass grafting in Brazil

There is often a negative association between the volume of medical procedures and hospital mortality rates. The objective of this study is to determine whether this association is observed in Brazilian hospitals performing coronary artery bypass grafts (CABG) that were financed by the Ministry of Health. CABG surgeries performed from 1996 to 1998 were analyzed. Data were collected from the Ministry of Health Hospital Information System. The statistical procedure utilized was the Cox survival analysis. Hospitals were grouped in classes of volume of CABG performed. The model was adjusted to the severity of cases (risk of dying). From January 1996 to December 1998 the Ministry of Health reimbursed 41,989 CABG procedures in 131 hospitals. The overall hospital mortality rate was 7.2%. A gradient was observed in the mortality rates. The severity-adjusted risk of dying in the group of hospitals performing more procedures was lower than in the group performing fewer operations. It is recommended that the Ministry of Health strongly consider regionalized concentration of services to perform CABG.